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APA 3 - Wolfe > Spinals and Epidurals > Flashcards

Spinals and Epidurals Flashcards

1
Q

What are the types of needles

A

Pencil (better feel, less trauma)

Cutting (place longitudinal)

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2
Q

Name the 4 spinal needles

A

Quincke (medium cutting)
Pinkin (cutting)

Sprotte (pencil point)
Whitacre (pencil point)
Pencan (pencil point)

Greene (noncutting rounded bevel)

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3
Q

Name the 3 epidural needles

A

Crawford (0 degrees)
Hustead (15 degrees)
Touhy (30 degrees)

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4
Q

What does a stylet in the needle do?

A

Prevents introduction of dermal cells

can lead to dermoid spinal cord tumor

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5
Q

What are the needle sizes?

A

22-27 gauge

90-145mm

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6
Q

ABSOLUTE contraindications to a spinal

A 
PATIENT REFUSAL
Lack of Cooperation
Uncorrected coagulopathies
Infection at the site of block
Hypovolemia
Indeterminate neurologic disease
Increased ICP
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7
Q

Relative contraindications to a spinal

A

Infection distinct from site of injection

Unknown duration of surgery

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8
Q

Uptake and spread from subarachnoid space depends on

A

Concentration of LA in CSF
Surface area of nerve tissue exposed
Lipid content of nerve tissue
Blood flow to nerve tissue

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9
Q

Distribution of LA depends on

A

Baricity
Position
Dose

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10
Q

The level of spread depends on

A 
Baricity 
Position
Dose
Site of injection
Age?
Speed of injection
Volume
Concentration
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11
Q

Specific gravity of CSF

A

0.002-0.009

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12
Q

Define baricity

A

the density of a LA relative to CSF

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13
Q

Define Isobaric

A

Baricity similar to CSF
LA will remain in place
Saline added

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14
Q

Define hyperbaric

A

Baricity higher than CSF
LA will sink
Dextrose added to increase baricity

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15
Q

Define hypobaric

A

Baricity lower that CSF
LA will rise
Water added to reduce baricity

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16
Q

Systemic effects of Neuraxial anesthesia:

Liver and Kidneys

A

if MAP maintained, no changes

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17
Q

Systemic effects of Neuraxial anesthesia

Cadiovascular

A

Sympathectomy - vasodilation of arterial and venous capacitant vessels (venous predominantly). Reduction in venous return, CO and BP

Volume load with 15ml/kg

Bradycardia from block of cardiac accelerators (T1-T4) and Bezold-Jarish reflex)

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18
Q

Systemic effects of Neuraxial anesthesia

Respiratory

A

Little effect with normal lung physiology

Accessory muscle function reduced (imprint of inspiratory & expiratory and ability to cough)

Major effect with high spinal

Loss of proprioceptive input = dyspnea feeling (maintain reassurance, if they can talk, they can breath)

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19
Q

Systemic effects of Neuraxial anesthesia

GI

A

Sympathetic innervation from T6-L2

  • Increased secretions
  • Sphincters relax
  • Bowel constricts

Nausea and Vomiting about 20%
- Atropine to treat after high spinal

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20
Q

Systemic effects of Neuraxial anesthesia

CNS

A

Reduced sensory input from the reticular activating system (RAS) can lead to drowsiness

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21
Q

Which LA is NOT approved for spinal

A

2-Chloroprocaine

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22
Q

Which LA are approved for spinals

A

Lidocaine
Tetracaine
Bupivacaine

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23
Q

What is the spinal inset/duration/dose for Lidocaine

A

Onset: 3-5 min
Duration: 60-90 min
Dose: 25-50 mg

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24
Q

What is the spinal onset/duration/dose for Tetracaine

A

Onset: 3-6 min
Duration: 70-180 min
Dose: 5-20mg

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25
Q

What is the spinal onset/duration/dose for Bupivacaine

A

Onset: 5-8 min
Duration: 90-150 min
Dose: 5-20 mg

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26
Q

When you ID the iliac crest for spinal placement, what level are you at?

A

L4-L5

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27
Q

When doing a midline approach,
Needle angle degree…
Resistance at all layer, but mostly at..
Remove stylet and check for flow, if no what..
After free flowing CSF, attach syringe and..

A

Slightly cephalad 10-15 degrees
Ligamentum flavus (will feel a pop when thru)
Rotate needle (may be up against something)
Aspirate, inject slow (0.5 ml/sec)

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28
Q

Complications during spinal placement:

Bone contacted

A

Withdraw needle and stylet to skin and redirect

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29
Q

Complications during spinal placement:

Paresthesia

A

Stop advancing

Remove stylet and check for CSF

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30
Q

Complications during spinal placement:

Blood

A

Not usually a problem unless excessive

Reattempt

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31
Q

Complications during spinal placement:

Position

A

May use table to alter block during first few minutes

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32
Q

When placing a spinal needle via midline approach, what structures do you meet (in order)

A 
Skin
Subcutaneous
Supraspinous Ligament
Intraspinous Ligament
Ligamentum Flavum
(epidural space)
Dura mater
(subdural space)
Arachnoid mater
(subarachnoid space- spinal placement)
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33
Q

What is the paramedic approach good for?

A

Good for calcified intraspinous ligament or difficult positioning

34
Q

The needle will pass through 1 ligament during the paramedium approach, which one

A

Ligamentum Flavum

35
Q

How is the needle inserted for paramedium approach?

A

1 cm lateral and 1 cm inferior to space
Angle needle medially and cephelad

If lamina contacted, walk off bone

36
Q

If a patient receives a spinal, what must they do before being discharged?

A

Must void prior to discharge

37
Q

Complications from spinal

Neurologic Injury

A
  1. 03% occurance (1:240,000)
    - Needle introduction to nerve or cord
    - Spinal cord ischemia
    - Bacterial contamination
    - Hematoma
38
Q

Complications from spinal

Cauda Equina Syndrome

A

Microcatheters

5% lido, repeated dosing

39
Q

Complications from spinal

Arachnoiditis

A 
Infection
Myelograms from oil based dyes
Blood
Neuro irritant
Surgical interventions
Intrathecal steriods
Trauma
40
Q

Complications from spinal

Meningitis

A

Bacterial or aseptic

Use Strict sterile technique

41
Q

Complications from spinal
Postdural puncture headache
- up to __% incidence
- what makes it worse/better

A

25%

Worse when head up, relief when supine

42
Q

Non-invasive treatment for PDPH

A 
Fluids
Caffeine (500mg 1-2 doses)
Bed rest
Analgesics
Sumatriptan

May take up to 1-6 weeks to resolve

43
Q

Invasive treatment for PDPH

A

Epidural Blood Patch

Mainstay of invasive treatment
1st effective up to 64% OB and 95% non-OB
2nd effective up to 90%

44
Q

Complications from spinal
Spinal Hematoma

Why is this important to diagnose?
What increased the risk?

A

This is a MEDICAL EMERGENCY

  • Neurologic symptoms
  • Immediate neuro consult and MRI

Incidence 0.00063%
Anticoagulation, increased age, female, hx of GI bleed, length of therapy

45
Q

Complications from spinal

High Spinal

A

Monitor and treat appropriately

Airway and Pressor support

46
Q

Complications from spinal
CV collapse

What is the 1st S/S?

A

Bradycardia usually 1st

Treat aggressively

47
Q

Absolute contraindications to epidurals

A

patient refusal
uncorrected hypovolemia
increased ICP
infection at site

48
Q

Relative contraindications to epidurals

A

coagulopathy
fixed cardiac defect
anatomic abnormalities
unstable neurologic disease

49
Q

Controversial contraindications to epidurals

A

inability to communicate, tattoos, complicated surgery with major blood loss

50
Q

Where is the epidural placed?

A

Usually at L2-L4

51
Q

When can you use adult levels for epidural placement?

A

after age 8

52
Q

Physiologic effects spinal to spinal
Above T4
Below T4

A

Above T4
T1-T4 cardiac sympathetic fibers
Profound hypotension and bradycardia

Below T4
Vasomotor tone controlled by T5-L1
Decreased venous return, and subsequent decreased CO

53
Q

If pt has respiratory arrest after epidural, what was it most likely from?

A

likely due to sympathectomy and brain and brainstem ischemia

54
Q

What is the key factor effecting epidural coverage

A

Volume**

Adults: 1-2 mL for each level to be blocked
Lumbar gets more spread cephalad than caudal
Thoracic even spread up and down

55
Q

How does concentration effect coverage for epidural?

A

Lower – sensory

Higher – may get motor

56
Q

Is position a factor for epidural spread?

A

NO

57
Q

How does age effect coverage for epidural?

A

Inreased age = decreased dose

58
Q

How does height effect coverage for epidural?

A

<5’2” use 1mL per level

>5’2” increase by 0.1mL for each 2 inches

59
Q

How does pregnancy and obesity effect coverage?

A

Decreased dose

Epidural vein engorgement and increased adipose tissue

60
Q

What is average onset time for epidural

A

10-20 min

61
Q

What are the approaches for epidural placement

A

Median
Paramedian start 1.5-2cm laterally
Taylor

62
Q

What are the 2 techniques for IDing epidural space

A

Loss of resistance (LOR)

Hanging drop

63
Q

Explain LOR technique

A

Place needle & stylet through supraspinous ligament and into intraspinous ligament
Remove stylet and attach syringe with air or fluid
Always secure needle against patient

2 ways to proceed

1: Alternate very slow advancement and tapping pressure to plunger of syringe until LOR
2: Advance needle with continuous pressure on plunger until LOR

64
Q

Explain hanging drop technique

A

Needle placed as before
Small amount of fluid placed in needle hub
Needle advanced until Epidural space encountered
Drop will suck into needle

Used mostly for Thoracic

65
Q

For a caudal block, how is the sacral hiatus ID’d?

A

ID’d by Sacral Cornu

66
Q

What angle is the needle inserted at for a caudal?

A

Needle inserted at 45 degree angle

67
Q

During a caudal, there is a distinct “snap” or “pop” when through which membrane?

A

sacrococcygeal membrane

68
Q

Once through the sacrococcygeal membrane, what are the next steps

A

Lower angle to 160 degrees

Advance :
Adults no more than 1.5 cm
Children no more than 0.5 cm

Aspirate for blood or CSF
Insert catheter or inject

69
Q

After IDing the epidural space with the needle, what are the next steps?

A
  • Note depth on needle
  • Place catheter through needle
  • Mark for end of needle and resistance
  • Advance catheter 5-7 cm more
  • Remove needle over catheter
  • Withdrawal catheter until 3-5 cm remain in epidural space
  • Attach end to catheter
  • Aspirate for blood or CSF
  • Dressing – clear occlusive
  • Test Dose
    (3 mL of 1.5% Lido with 15mcg epi)
70
Q

What should you NEVER do when placing an epidural catheter?

A

NEVER WITHDRAW CATHETER THROUGH NEEDLE***

71
Q

What should you always do before dosing an epidural?

A

ALWAYS ASPIRATE PRIOR TO INJECTION

72
Q 
What is the dosing for
Lumbar
Thoracic
Caudal
Continuous infusion
A

Lumbar:
1-2 mL per segment
Give in 5 mL increments q 3-5 min

Thoracic:
0.7 mL per segment
3-6 mL q 30 min

Caudal:
3 mL per segment

Continuous infusion:
4-15 mL/hr (Individualize)

73
Q

With an epidural, what should be done if you have a unilateral block?

A

Pull catheter back
Unaffected side down
Redose
Replace

74
Q

With an epidural, what should be done if you have an inadequate block?

A

Raise head & redose with higher concentration

Add fentanyl or give 50 mcg

75
Q

With an epidural, what should be done if there is questionable quality and pt needs to go to OR?

A

In OR remove catheter

Do CSE with new catheter placement

76
Q

With an epidural, what should be done if you have a dissipating block?

A

Requires more or doesn’t last
Check for intravascular placement
Rebolus with higher concentration & increase rate
Add opiod

77
Q

What is the incidence of back pain with epidurals?

What is the treatment?

A

20-30% incidence
Usually self limiting

NSAIDS, Tylenol, Heat

78
Q

PDPH is more common in what group and after what accidentally happens?

A

Most common in younger female

Usually expected after wet tap

79
Q

If inadvertent subdural injection, when will you see it?

A

Delayed response 10-15 minutes
Get ready for High spinal

(hallmark - high but patchy block)

80
Q

If inadvertent subarachnoid injection, when will you see it?

A

Fast high spinal

81
Q

What are they symptoms and treatment for men

A

Non-positional headache, fever, lethargy, confusion and classic nuchal rigidity

Emergent antibiotic therapy
Head CT, lumbar puncture, neuro consult

82
Q

Arachnoiditis

Also thought to be from adherence of ____

A

tissue pulling

APA 3 - Wolfe (11 decks)

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